Provider Demographics
NPI:1386040103
Name:ALLISON-CLARK, LETICIA LANAY (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:LANAY
Last Name:ALLISON-CLARK
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WEST COLLIER STREET
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-3350
Mailing Address - Country:US
Mailing Address - Phone:636-279-5907
Mailing Address - Fax:
Practice Address - Street 1:100 WEST COLLIER STREET
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-3350
Practice Address - Country:US
Practice Address - Phone:636-279-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008033359225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist